Comparison of the 3D-Exoscope and Operating Microscope in Mastoidectomy.

OBJECTIVES: The operating microscope (OM) commonly used in ear surgeries has several disadvantages, including a low depth of field, a narrow field of view, and unfavorable ergonomic characteristics. The exoscope (EX) was developed to overcome these disadvantages. Herein, we compared OM and EX during mastoidectomy and found out the feasibility of the EX. STUDY DESIGN: Prospective randomized comparative study. SETTING: Tertiary academic medical center. PATIENTS: Patients who had mastoidectomy for chronic otitis media with or without cholesteatoma between January 2022 and April 2022. INTERVENTION: Canal wall-up mastoidectomy (CWUM) or canal wall-down mastoidectomy (CWDM) using OM or EX without endoscope. MAIN OUTCOME MEASURES: Operative setting time (the time between the end of general anesthesia and incision), operative time (from incision to suture), postoperative audiologic outcomes, perioperative complications, and the decision to switch from EX to OM. RESULTS: Of 24 patients who were diagnosed with chronic otitis media or cholesteatoma, 12 each were randomly assigned to the OM or EX group. The mean operation time was 175 ± 26.5 minutes and 172 ± 34.6 minutes in the EX and OM group, respectively, which was not significantly different ( p = 0.843). The procedures in the EX group were successfully completed using a three-dimensional (3D)-EX without conversion to OM. All surgeries were completed without any complications. The postoperative difference in the air and bone conduction was 11.2 and 12.4 dB in the EX and OM groups, respectively, which was not significantly different ( p = 0.551). CONCLUSIONS: EX is comparable to OM in terms of surgical time, complications, and audiologic outcomes following mastoidectomy. The EX system is a potential alternative to OM. However, further improvements are required to overcome some drawbacks (deterioration of image resolution at high magnification, requirement of an additional controller for refocusing).

The Effectiveness of Salvage Hyperbaric Oxygen Therapy Following Combined Steroid Therapy for Refractory Sudden Sensorineural Hearing Loss.

OBJECTIVE: Hyperbaric oxygen therapy (HBOT) is an accepted treatment option for sudden sensorineural hearing loss (SSNHL), but it is still recommended in combination with corticosteroids. We investigated the efficacy of salvage HBOT in refractory SSNHL that does not respond to corticosteroid combination therapy. METHODS: Eighty-four patients were included, who had unilateral SSNHL with an improvement of pure-tone average (PTA) less than 10 dB after using intratympanic plus systemic corticosteroids (combined therapy) as the initial therapy. The control group (n = 66) received no further treatment, and the HBOT group (n = 18) received additional treatment with HBOT (10 sessions in total with 2.5 atmospheres absolute for 1 hour). RESULTS: No differences in PTA or WDS were found between the 2 groups. However, the mean hearing gain in the HBOT group (16.8 ± 4.49 dB) was significantly higher than that in the control group (4.45 ± 1.03 dB) (P = .015). The proportion of patients with hearing recovery (hearing gain of 10 dB or more) after treatment was significantly higher in HBOT group (38.9%) than in the control group (10.6%). CONCLUSIONS: In patients with refractory SSNHL after steroid combined therapy, salvage HBOT showed a significant effect on hearing gain and recovery rate.

Surgical technique for complicated preauricular sinus: Pilot study of double elliptical excision with coaptation suture.

OBJECTIVES: Preauricular sinus (PAS) is a congenital anomaly that can progress to complicated cases with granulation tissue around the PAS area due to skin inflammation. Treatment involves incision and drainage or continuous dressing; however, surgical treatment may be necessary. We evaluated a surgical method for the effective treatment of complicated PAS. MATERIALS AND METHODS: We retrospectively reviewed the medical records of 152 patients with PAS who were treated at a tertiary medical institution between September 2015 and June 2022. Data regarding age, sex, preoperative history related to PAS, a joint operation with a plastic surgeon, operation time, admission duration, follow-up duration, and postoperative complications were collected. The study population was divided into single-excision and double-excision with coaptation suture groups. The clinical characteristics were analyzed and compared between the two groups. RESULTS: Surgical treatment for PAS was performed in 131 patients (166 ears) in the single-excision group and 21 patients (27 ears) in the double-excision group. The average age was 6.22 ± 4.06 years old, and the male-to-female ratio was similar in the single-excision group (M:F = 68:63) but higher for females in the double-excision group (M:F = 5:16) (p = 0.017). Joint surgeries with a plastic surgeon were more frequent in the double-excision group, and the operation time and admission duration were significantly longer. The preoperative history and postoperative complications (seven cases, 4.6 %) did not differ significantly between the two groups, although there was a higher percentage of complications in the double elliptical excision group. CONCLUSIONS: Double excision with one or more coaptation sutures is an effective one-step method for complicated PAS with an acceptable aesthetic appearance of the scar, although it requires a longer operation time and admission duration for wound care. Further studies with larger and more diverse patient populations are needed to validate these findings.

Prospective Study of Nonsurgical Auricular Correction According to Timing of Treatment.

BACKGROUND AND PURPOSE: Many studies recommend nonsurgical auricular correction during the early postnatal period, when cartilage plasticity is high; however, many patients are not eligible for the procedure. This study compared different timings of nonsurgical auricular correction to investigate benefit after the optimal period for correction. METHODS: In this prospective study, 53 ears from 35 patients with congenital auricular anomaly were assigned to two groups according to age at correction: the "early-group" with correction within 2 weeks of birth and "late-group" with correction 8 weeks after birth. Aesthetic outcomes, caregiver satisfaction, detachment rates and mean device-wearing periods, were compared. RESULTS: Thirty-one ears from 20 patients comprised the early-group, and 18 ears from 12 patients comprised the late-group. Mean time to treatment after birth was 9.09 days in the early-group and 134.7 days in the late-group. In the early-group, detachment occurred in 4/31 ears (12.9%), and in the late-group, detachment occurred in 12/18 ears (66.7%), which was statistically significant (p<0.01). The average period of applying devices was 4.7 ± 1.2 weeks in the early-group and 8.5 ± 4.1 weeks in the late-group, with a significantly longer treatment time in the late-group (p=0.001). The early-group had 87.1% "good" results vs. 55.6% in the late-group, with a statistically significant difference. CONCLUSIONS: The correction period was shorter, detachment rate was lower, and treatment outcome was better in the early-group. However, successful correction was also present in the late-group, showing that the patients who have passed the optimum correction period should proceed after counselling.

Differences in the metabolomic profile of the human palatine tonsil between pediatrics and adults.

Palatine tonsils (PT) are B cell-predominant lymphoid organs that provide primary immune responses to airborne and dietary pathogens. Numerous histopathological and immunological studies have been conducted on PT, yet no investigations have been conducted on its metabolic profile. We performed high-resolution magic angle spinning nuclear magnetic resonance spectroscopy-based metabolic profiling in 35 pediatric and 28 adult human palatine tonsillar tissue samples. A total of 36 metabolites were identified, and the levels of 10 metabolites were significantly different depending on age. Among them, partial correlation analysis shows that glucose levels increased with age, whereas glycine, phosphocholine, phosphoethanolamine, and ascorbate levels decreased with age. We confirmed the decrease in immunometabolic activity in adults through metabolomic analysis, which had been anticipated from previous histological and immunological studies on the PT. These results improve our understanding of metabolic changes in the PT with aging and serve as a basis for future tonsil-related metabolomic studies.

Hearing recovery prediction and prognostic factors of idiopathic sudden sensorineural hearing loss: a retrospective analysis with a deep neural network model.

OBJECTIVE: Idiopathic Sudden Sensorineural Hearing Loss (ISSHL) is an otologic emergency, and an early prediction of prognosis may facilitate proper treatment. Therefore, we investigated the prognostic factors for predicting the recovery in patients with ISSHL treated with combined treatment method using machine learning models. METHODS: We retrospectively reviewed the medical records of 298 patients with ISSHL at a tertiary medical institution between January 2015 and September 2020. Fifty-two variables were analyzed to predict hearing recovery. Recovery was defined using Siegel's criteria, and the patients were categorized into recovery and non-recovery groups. Recovery was predicted by various machine learning models. In addition, the prognostic factors were analyzed using the difference in the loss function. RESULTS: There were significant differences in variables including age, hypertension, previous hearing loss, ear fullness, duration of hospital admission, initial hearing level of the affected and unaffected ears, and post-treatment hearing level between recovery and non-recovery groups. The deep neural network model showed the highest predictive performance (accuracy, 88.81%; area under the receiver operating characteristic curve, 0.9448). In addition, initial hearing level of affected and non-affected ear, post-treatment (2-weeks) hearing level of affected ear were significant factors for predicting the prognosis. CONCLUSION: The deep neural network model showed the highest predictive performance for recovery in patients with ISSHL. Some factors with prognostic value were identified. Further studies using a larger patient population are warranted. LEVEL OF EVIDENCE: Level 4.

Effects of Particulate Matter Exposure on the Eustachian Tube and Middle Ear Mucosa of Rats.

OBJECTIVES: Particulate matter (PM) is a risk factor for various diseases. Recent studies have established an association between otitis media (OM) and PM exposure. To confirm this relationship, we developed a novel exposure model designed to control the concentration of PM, and we observed the effects of PM exposure on the Eustachian tube (ET) and middle ear mucosa of rats. METHODS: Forty healthy, 10-week-old, male Sprague-Dawley rats were divided into 3-day, 7-day, 14-day exposure, and control groups (each, n=10). The rats were exposed to incense smoke as the PM source for 3 hours per day. After exposure, bilateral ETs and mastoid bullae were harvested, and histopathological findings were compared using microscopy and transmission electron microscopy (TEM). The expression levels of interleukin (IL)-1ß, IL-6, tumor necrosis factor-α, and vascular endothelial growth factor (VEGF) in the middle ear mucosa of each group were compared using real-time reverse transcription polymerase chain reaction (RT-PCR). RESULTS: In the ET mucosa of the exposure group, the goblet cell count significantly increased after PM exposure (P=0.032). In the middle ear mucosa, subepithelial space thickening, increased angio-capillary tissue, and inflammatory cell infiltration were observed. Moreover, the thickness of the middle ear mucosa in the exposure groups increased compared to the control group (P<0.01). The TEM findings showed PM particles on the surface of the ET and middle ear mucosa, and RT-PCR revealed that messenger RNA (mRNA) expression of IL-1ß significantly increased in the 3-day and 7-day exposure groups compared to the control group (P=0.035). VEGF expression significantly increased in the 7-day exposure group compared to the control and 3-day exposure groups (P<0.01). CONCLUSION: The ET and middle ear mucosa of rats showed histopathologic changes after acute exposure to PM that directly reached the ET and middle ear mucosa. Therefore, acute exposure to PM may play a role in the development of OM.

Outcomes of Endoscopic Tympanoplasty for Large Perforations: A Multicenter Retrospective Study in South Korea.

OBJECTIVES: Endoscopic tympanoplasty (ET) provides minimally invasive transcanal access to the middle ear and improves middle ear visibility for the treatment of tympanic membrane (TM) perforations. However, the literature on surgical outcomes for large TM perforations is lacking and limited to small series. This study aimed to evaluate the clinical benefits of ET for large TM perforations. METHODS: This retrospective cohort study was conducted at nine tertiary referral hospitals in South Korea, where 252 patients who underwent ET as primary surgery from September 2019 to August 2021 were included. The outcome measures included the graft success rate and pre- and postoperative audiometric data. RESULTS: In 239 patients, the graft success rate of ET for large or subtotal perforations was 86.2% (206 patients), while the graft failure rate was 13.8% (33 patients). The graft failure rate was directly correlated with surgical techniques, including overlay and medial or lateral underlay tympanoplasty (P=0.027). Lateral underlay tympanoplasty showed the most favorable. RESULTS: Sex, laterality, etiology, site and size of perforation, operation time, and graft materials did not vary significantly between the graft success and failure groups (P>0.05). The mean air-bone gap (ABG) improved significantly in both groups (graft success group: 10.0±0.6 dB and graft failure group: 7.7±0.3 dB; P<0.001). However, the ABG improvement did not significantly differ between the groups. Analysis of covariance revealed that the postoperative 500-Hz bone conduction threshold improved after successful ET (adjusted coefficient, -11.351; 95% confidence interval, -21.491 to -1.212; P=0.028). CONCLUSION: This study involved the largest population to date of large TM perforations treated by ET. The study findings suggest that ET is feasible and effective in treating large TM perforations.

Outcomes of Endoscopic Congenital Cholesteatoma Removal in South Korea.

Importance: Transcanal endoscopic ear surgery (TEES) provides minimally invasive transcanal access to the middle ear and improves middle ear visibility during cholesteatoma resection. However, the literature on outcomes following TEES alone for the removal of congenital cholesteatoma (CC) is lacking and limited to small series. Objective: To assess outcomes of TEES for CC limited to the middle ear and/or mastoid antrum and to explore the risk factors associated with recidivism (ie, recurrent and/or residual cholesteatoma). Design, Setting, and Participants: This cohort study evaluated retrospective, multicenter data for 271 children with CC who underwent TEES at 9 tertiary referral hospitals in South Korea between January 1, 2013, and December 31, 2021, and had a follow-up of at least 6 months after surgery. Main Outcomes and Measures: Outcomes included the incidence of residual cholesteatoma and audiometric data after TEES. A multivariable analysis using Cox proportional hazards regression models was used to assess associations between cholesteatoma characteristics and recidivism, with hazard ratios (HRs) and 95% CIs reported. Results: Of the 271 patients (mean [SD] age, 3.5 [2.9] years; 194 [71.6%] boys, 77 [28.4%] girls), 190 had Potsic stage I CC (70.1%), 21 (7.7%) had stage II, 57 (21.0%) had stage III, and 3 (1.1%) had stage IV. Thirty-six patients (13.3%) with residual cholesteatoma were found, including 15 (7.9%) with Potsic stage I, 3 (14.3%) with stage II, and 18 (31.6%) with stage III. In the multivariable analysis, invasion of the malleus (HR, 2.257; 95% CI, 1.074-4.743) and posterosuperior quadrant location (HR, 3.078; 95% CI, 1.540-6.151) were associated with the incidence of recidivism. Overall, hearing loss (>25 dB on auditory behavioral test or >30 dB of auditory evoked responses) decreased from 24.4% to 17.7% after TEES. Conclusions and Relevance: This cohort study involved the largest known population to date of CC removed by TEES. The findings suggest that TEES may be feasible and effective for the removal of CC limited to the middle ear and/or mastoid antrum in children.

The Optimized Protocol of Hyperbaric Oxygen Therapy For Sudden Sensorineural Hearing Loss.

OBJECTIVE: This study aimed to determine the optimal protocol of hyperbaric oxygen therapy (HBOT) according to various treatment settings for sudden sensorineural hearing loss (SSNHL). METHODS: A 112 patients with SSNHL were enrolled in this prospective study. All patients were treated with systemic steroid therapy, intratympanic steroid therapy, and HBOT. According to the pressure and duration of HBOT (10 sessions in total), the patients were divided into three groups: group 1, 2.5 atmospheres absolute (ATA) for 1 h; group 2, 2.5 ATA for 2 h; and group 3, 1.5 ATA for 1 h. The pure-tone average (PTA), word discrimination score (WDS), and mean gain were compared. RESULTS: A total of 105 patients completed the 3-month follow-up, and 6 patients were excluded. Differences among groups were found in PTA, WDS, and mean gain. In the post-hoc analysis, group 3 had significantly lower WDS and mean gain than groups 1 and 2; however, group 2 showed no significant differences from group 1. The proportion of patients with hearing recovery after treatment was significantly higher in group 1 (57.6%) and group 2 (58.8%) than in group 3 (31.3%). CONCLUSIONS: When HBOT (10 sessions) was combined with corticosteroids as the initial therapy for SSNHL, a higher pressure (1.5 ATA vs. 2.5 ATA) provided better treatment results; however, increasing the duration (1 h vs. 2 h) under 2.5 ATA did not result in a significant difference. Therefore, HBOT for SSNHL may be performed at 2.5 ATA for 1 h in 10 sessions. Laryngoscope, 133:383-388, 2023.

Auricular Reconstruction for Bilateral Auricular Deformity Caused by Relapsing Polychondritis.

This case report describes a woman in her early 20s who presented to the hospital with an acquired auricular deformity after an ear piercing and was diagnosed with recurrent polychondritis that required total auricular reconstruction.

Hearing recovery prediction and prognostic factors of idiopathic sudden sensorineural hearing loss: a retrospective analysis with a deep neural network model

Abstract Objective Idiopathic Sudden Sensorineural Hearing Loss (ISSHL) is an otologic emergency, and an early prediction of prognosis may facilitate proper treatment. Therefore, we investigated the prognostic factors for predicting the recovery in patients with ISSHL treated with combined treatment method using machine learning models. Methods We retrospectively reviewed the medical records of 298 patients with ISSHL at a tertiary medical institution between January 2015 and September 2020. Fifty-two variables were analyzed to predict hearing recovery. Recovery was defined using Siegel's criteria, and the patients were categorized into recovery and non-recovery groups. Recovery was predicted by various machine learning models. In addition, the prognostic factors were analyzed using the difference in the loss function. Results There were significant differences in variables including age, hypertension, previous hearing loss, ear fullness, duration of hospital admission, initial hearing level of the affected and unaffected ears, and post-treatment hearing level between recovery and non-recovery groups. The deep neural network model showed the highest predictive performance (accuracy, 88.81%; area under the receiver operating characteristic curve, 0.9448). In addition, initial hearing level of affected and non-affected ear, post-treatment (2-weeks) hearing level of affected ear were significant factors for predicting the prognosis. Conclusion The deep neural network model showed the highest predictive performance for recovery in patients with ISSHL. Some factors with prognostic value were identified. Further studies using a larger patient population are warranted. Level of evidence: Level 4.

Patulous eustachian tube after balloon eustachian tuboplasty in a post-radiation patient.

BACKGROUND: Balloon eustachian tuboplasty (BET) is a minimally invasive surgical treatment that is effective and safe for obstructive eustachian tube dysfunction. However, BET complications include excessive widening of the eustachian tube, causing a patulous eustachian tube (PET). Herein, we report a case of PET following BET in a patient who underwent radiation therapy and reviewed the literature on considerations for reducing complications after BET. CASE PRESENTATION: A 63-year-old woman complained of bilateral ear fullness after concurrent chemoradiation therapy for nasopharyngeal lymphoma. BET was performed on the left side because the left-sided serous otitis media persisted. A left-sided PET was performed two weeks after the BET, along with eustachian tube silicone plug insertion on the left side. The patient became asymptomatic immediately after the surgery, with no recurrence reported after a 12-month follow-up period. CONCLUSIONS: To our knowledge, there has been no report of PET following BET in a post-radiation patient, and it was successfully treated via ET silicone plug insertion.

Clinical features and prognosis of severe-to-profound sudden sensorineural hearing loss.

PURPOSE: Sudden sensorineural hearing loss (SSNHL) is an otologic emergency. Despite multiple efforts to clarify the factors affecting the prognosis of severe-to-profound SSNHL, various studies showed inconsistent results and lack of clinical significance. Therefore, we examined the clinical features and outcomes of severe-to-profound SSNHL. MATERIALS AND METHODS: We included patients who experienced SSNHL between 2018 and 2021 and were diagnosed according to the American Academy of Otolaryngology-Head and Neck Surgery criteria; hearing loss over 70 dB on initial pure tone audiometry (PTA) was used to define severe-to-profound SSNHL. We retrospectively examine the demographic, laboratory, radiologic, and audiometric data of SSNHL patients. We also evaluated the final hearing gain of these patients by assessing their PTA findings and word-recognition scores. RESULTS: Of the 178 patients, 94 (52.81%) and 84 (47.19%) showed profound (>90 dB) and severe (>70 to 90 dB) hearing loss, respectively. The presence of vertigo and hypertension differed significantly between the severe and profound groups (p < 0.001 and p = 0.012, respectively), as did the initial serum creatinine level (p = 0.043). Recovery in PTA showed a reliable correlation with the interval between onset and treatment in the severe group and periventricular white-matter findings in the profound group (p < 0.001 and p = 0.011, respectively). The presence of hypertension was related to recovery of low tone (p = 0.023 for 250 Hz; p = 0.034 for 500 Hz), while glycated hemoglobin level was related to recovery of high tone in the severe group (p = 0.049 for 4000 Hz; p = 0.047 for 8000 Hz). CONCLUSIONS: Severe-to-profound SSNHL showed poor prognosis for hearing gain. The interval from onset to treatment was a significant prognostic factor for severe SSNHL, while the presence of vertigo, estimated glomerular filtration rate, and periventricular white-matter findings were significant prognostic factors for profound SSNHL.

The Clinical Value of Periventricular White Matter Hyperintensity on MRI in Sudden Sensorineural Hearing Loss.

OBJECTIVES: To assess the clinical value of periventricular white matter hyperintensity (PWMH) found on brain magnetic resonance imaging (MRI) in patients with sudden sensorineural hearing loss (SSNHL). METHODS: In this prospective study, 115 patients who were diagnosed with SSNHL aged between 55 and 75 years were analyzed. All subjects underwent brain MRI and were divided into a PWMH and control groups, depending on the presence of PWMH on MRI. PWMH was subdivided into 3 groups according to severity. Pure-tone average results and hearing gain were compared between the 2 groups before treatment and 2 months after treatment. Hearing improvement was assessed using Sigel's criteria. RESULTS: A total of 106 patients (43 in the PWMH group and 63 in the control group) finally completed the 2-month follow-up. Average hearing gain in the PWMH group was significantly higher than in the control group (34.8 ± 20.3 and 25.9 ± 20.3, respectively, P = .029). PWMH score 1 showed significantly better hearing levels and hearing gain compared to PWMH score 3 and the control group. Multivariate analysis revealed that younger age, better initial hearing level, and the presence of PVWM score 1 were associated with good recovery. CONCLUSIONS: The presence of PWMH score 1 on brain MRI in patients with SSNHL was associated with better treatment response and was a good prognostic factor in a multivariate analysis while the hearing recovery in more severe PWMH (scores 2, 3) was not different from the control group.

Device failure caused by the dissociation of floating mass transducer in Vibrant SoundBridge®.

BACKGROUND: Vibrant SoundBridge® (VSB), a semi-implantable middle ear device, is one of the treatment options for patients with mild-to-severe sensorineural hearing loss or mixed hearing loss. Herein, we report delayed device failure after VSB surgery in two patients. CASE PRESENTATION: In both cases, a revision surgery was performed for the removal of the device; dissociation of the floating mass transducer (FMT) and coupler was noticed in one patient, and dissociation of the FMT-coupler complex from the short process of the incus in the other. In Case 1, the vibration-like sounds disappeared after the surgery. In Case 2, wearing bilateral hearing aids improved hearing after removal surgery, but complaints regarding speech discrimination persisted. Both cases show the importance of not loosening the connectivity between the FMT, coupler, and short process of the incus during VSB surgery. CONCLUSIONS: To our knowledge, there has been no report of dissociation from the short process of the incus or the dissociation between an FMT and the coupler.